What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

For immunocompetent adults with shingles, initiate oral valacyclovir 1 gram three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily, starting within 72 hours of rash onset and continuing until all lesions have completely scabbed. 1, 2, 3

First-Line Oral Antiviral Therapy

The three FDA-approved oral antivirals are equally effective at reducing viral shedding, accelerating lesion healing, and decreasing acute pain duration. 4, 5 However, valacyclovir and famciclovir offer superior convenience with three-times-daily dosing compared to acyclovir's five-times-daily regimen, which may improve adherence. 1, 4

Critical timing considerations:

• Treatment is most effective when initiated within 48 hours of rash onset 3
• The maximum window for optimal efficacy is 72 hours after rash appearance 2, 6
• Continue therapy until all lesions have completely scabbed—this is the key clinical endpoint, not an arbitrary 7-day duration 1, 2

Specific dosing from FDA labels:

• Valacyclovir: 1 gram orally three times daily for 7 days 3
• Famciclovir: 500 mg orally three times daily for 7 days 6
• Acyclovir: 800 mg orally five times daily for 7 days 3

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 5-10 mg/kg every 8 hours for: 1, 2

• Disseminated herpes zoster (multi-dermatomal or visceral involvement)
• Severely immunocompromised patients with active disease
• Facial zoster with suspected CNS involvement or severe ophthalmic complications
• Any patient showing signs of cutaneous or visceral dissemination 5

For immunocompromised patients (such as those on chemotherapy, transplant recipients, or HIV-infected individuals), consider starting with IV acyclovir and temporarily reducing immunosuppressive medications if disseminated disease is present. 1, 2

Special Populations and Dose Adjustments

Immunocompromised patients:

• HIV-infected patients may require higher oral doses (up to 800 mg 5-6 times daily) or IV therapy 1
• Transplant recipients with uncomplicated disease can receive standard oral dosing 1
• Patients on proteasome inhibitors (like bortezomib) should receive prophylactic acyclovir 400 mg daily to prevent herpes zoster 1

Renal impairment requires dose reduction: 2

• Valacyclovir: reduce to 1 gram every 12 hours for CrCl 30-49 mL/min; 1 gram every 24 hours for CrCl 10-29 mL/min
• Monitor renal function closely during IV acyclovir therapy with dose adjustments as needed 1

Adjunctive Corticosteroid Therapy

Prednisone may be considered as adjunctive therapy only in select cases of severe, widespread shingles in immunocompetent patients. 1, 2 However, the evidence for corticosteroids is inconsistent—one study showed no added benefit over acyclovir alone, while another suggested improved quality of life. 7

Absolute contraindications to corticosteroids: 2

• Immunocompromised patients (increased risk of disseminated infection)
• Poorly controlled diabetes
• History of steroid-induced psychosis
• Severe osteoporosis

Critical Pitfalls to Avoid

• Never use topical antiviral therapy alone—it is substantially less effective than systemic treatment 1, 2
• Do not delay treatment waiting for laboratory confirmation; diagnosis is clinical 1
• Antivirals do not eradicate latent virus but control symptoms and reduce complications 1, 2
• Patients remain contagious until all lesions have crusted and should avoid contact with varicella-susceptible individuals (pregnant women, immunocompromised persons, those without chickenpox history) 8, 2

Special Considerations for Facial Involvement

Facial zoster (including Ramsay Hunt syndrome affecting the ear) requires urgent treatment with oral valacyclovir 1 gram three times daily plus systemic corticosteroids, initiated within 72 hours. 9 Facial involvement carries risk of ophthalmic complications, cranial nerve involvement, and permanent sequelae. 1, 9

Red flags requiring ophthalmology referral: 10

• Lesions on the tip of the nose (Hutchinson's sign)
• Periorbital involvement
• Visual changes or eye pain

Prevention of Future Episodes

The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior shingles episodes. 1, 2 Vaccination should ideally occur before initiating immunosuppressive therapies. 1, 2

Monitoring and Follow-Up

• Assess for complete healing of lesions (all scabbed) before discontinuing therapy 1, 2
• Monitor for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in immunocompromised patients receiving high-dose valacyclovir 1, 2
• If lesions persist despite adequate antiviral therapy, consider acyclovir resistance and switch to IV foscarnet or cidofovir 8, 1